Initial Examination

Client Report: John was referred to physical therapy after his physician discontinued the painkillers he was taking because they started to cause severe stomach distress.

Client Goal: To decrease pain so that he can continue to coach his son’s soccer team

General Health: Good

Medications: None

Musculoskeletal: ROM: Trunk, bilateral upper extremities, left lower extremity=WNLs throughout; right knee extension/flexion=5 to 110 degrees; posture: WNLs

Neuromuscular: Force generation: trunk and bilateral upper extremities=5/5 throughout; left lower extremity=5/5 throughout; right hip flexors/extensors, abductors/adductors=5/5; right hip internal/external rotators, right knee flexors/extensors=4/5; right ankle=4/5 throughout

Function: Pain: Right knee pain, at rest=4/10; standing=5/10; after walking 1/4 mi.=7/10; running=8-9/10

Evaluation

The therapist determined that the client’s limited right knee ROM, pain, and weakness were consistent with a diagnosis of osteoarthritis of the knee. The therapist informed John that he can benefit from physical therapy interventions that address his knee pain and strength impairments at his knees and ankles.

Plan of Care

John attended four physical therapy sessions, which included ice and high-voltage electrical stimulation to the right knee, along with isokinetic exercises of both lower extremities. He also started a group aquatic exercise program at the local pool two times per week. He reported that the combination of physical therapy and the underwater exercise was helping him gain some lower extremity strength and muscular endurance, but he was frustrated that the pain relief he got from therapy did not last. He was instructed to ice his knee whenever he felt pain, but John reported that this was not always possible.

Reevaluation

A reexamination after eight sessions of physical therapy over 4 weeks demonstrated an improvement in the client’s lower extremity strength and reduction of pain at rest (3/10), after ambulating ¼ mi (5/10), and after running 1/8 mi. (7/10), but the pain was still too limiting for coaching his son’s soccer team. Transelectrical nervous stimulation (TENS) was then tried as an intervention to help John manage his pain, but he found it to be too cumbersome for the minimal pain relief it provided. John informed the therapist he had heard about TT from a friend and was wondering if it may help his knee pain.

Incorporating Cam into the Plan of Care

The therapist was aware that TT was a complementary therapy most often used with persons experiencing stress or anxiety but was uncertain of its application in persons with pain. The therapist considered the possibility that John may benefit from receiving TT as an adjunct to his rehabilitation program. She decided to find out more about TT by searching the scientific literature and contacting a TT practitioner whom she had met at a health care provider seminar at the local community center.

The therapist had developed a plan of care that included ice, high-voltage electrical stimulation, isokinetic exercise, and TENS and supported the client’s twice weekly aquatic exercise program. Although the client’s impairments of strength, pain, and muscular endurance were improving, he was still not able to achieve adequate long-term pain management necessary for coaching his son’s soccer team. To evaluate the appropriateness of a recommendation of TT for this client, the therapist needed to become familiar with TT and evaluate the evidence supporting its use in clients whose diagnosis or impairments were similar to John’s.

INVESTIGATING THE LITERATURE

The therapist uses two strategies to investig-ate the literature. The first is a detailed approach in which preliminary background reading is performed on TT. This is followed by a search of databases and evaluation of the literature using reviews and primary sources for TT and arthritic pain. The second is the use of the PICO format for a focused search to answer the clinical questions generated by the case.

Preliminary Reading

Several books written about TT ¹^–⁴ describe TT as a complementary therapy developed in the 1970s by Delores Krieger, RN, PhD, and Dora Kunz to promote health and healing. Persons with pain, anxiety, and a variety of other conditions are reported to benefit from receiving TT. Four assumptions form the basis for how and why TT is thought to facilitate health and healing. The first assumption as described by Krieger¹ is that the body is an open energy system, in which energy flows within and through the body in a dynamic interface with the environment. The second as-sumption suggests that individuals are bilaterally symmetrical so that the right and left sides of the body and the front and back mirror each other, which allows for a balanced flow of energy. The third assumption is that impairment in biological functioning, illness, or disease is associated with an imbalance of energy or an irregularity of energy flow through the body. The fourth assumption suggests that the body can achieve a process of self-healing through manipulation of subtle energy fields and restoration of appropriate energy levels and flow.¹

All the assumptions underpinning TT’s ap-proach and process to healing have their roots in the ancient Hindu concepts of prana and chakras.^3,⁵ Prana, equivalent to chi or qi, is considered to be a universal life energy that circulates through the universe and all living things. Chakras are energy centers positioned at strategic, vital areas of the human energy field that are associated with an endocrine gland and major nerve plexus. Chakras are able to receive, transform, and send prana through a vast network of interconnecting channels, known as nadis. A blockage, interruption, or imbalance of energy flow is thought to exist when disease or pathology exists within a bodily system or systems. Restoring or rebalancing an individual’s personal energy field or energy flow is important for the promotion of his or her own inner healing capabilities. Following a stepwise process, a TT practitioner can assess and modulate a client’s energy field with the intention of promoting self-healing.

Familiarity with how TT is applied or offered is important in consideration of its use. A practitioner administers TT in a four-step process. The first step, called centering, is a process in which practitioners center their consciousness so that a state of integration and quiet can be achieved.

From this state of centeredness, practitioners begin the assessment phase by placing their hands 2 to 3 inches from the client’s head and moving their hands down the client’s body, making note of the client’s energy field and acknowledging how the energy is perceived. A practitioner, for example, may describe a client’s energy as blocked or sluggish in a particular area.⁴ Or the energy may be perceived as vibratory, tingly, hot, or cold in some areas and not others. These observations may suggest that the practitioner should return to these areas later in the process (Figure 14-1).

Figure 14-1 Assessing the energy field.

Krieger ¹ has described the next step in the TT procedure as “unruffling the field.” During this activity, TT practitioners sweep away bound up or congested energy, which allows the final step of the process to begin with a client’s energy field being open and unrestricted (Figure 14-2). During the final stage of the TT process, practitioners can direct and modulate their own energy and/or the client’s energy in a specific manner to improve energy flow and balance. The intention is for the client’s energy flow to be balanced and the energy field to be symmetrical so that healing can occur (Figure 14-3).

Figure 14-2 Unruffling the energy field.

Figure 14-3 Moving congested energy in the shoulder area.

During a typical TT session, clients remain fully clothed and are seated in a chair. Sessions usually take approximately 20 to 30 minutes to complete, although practitioners report that some clients may require an hour-long session to achieve a relative state of energy balance. Frail clients and children may benefit from just 5 to 8 minutes of TT.⁶

Licensed health care providers and consumers should be aware if specific credentials or training are required to ensure the appropriate application of a therapeutic approach or modality. Despite the similarities between TT and the “laying-on-of hands” approach to healing, Krieger and Kunz do not believe that people need to be “chosen” by a higher entity to be a healer. They suggest that everyone is capable of developing a keen awareness of health and dysfunction and that anyone can heighten their perception of subtle energy if they desire to do so.¹ Krieger has been successful in integrating the teaching of TT into many nursing school curriculums across the United States and has endorsed the teaching of TT to anyone who is committed to helping others heal. According to Nurse Healers Professional-North America (NHP-NA), an organization that promotes the work and teaching of TT, more than 85,000 people have learned TT worldwide. Basic TT concepts are taught in 12-hour weekend workshops, although practice is required to develop proficiency and skill. NHP-NA recommends those practitioners wanting to practice in a medical or health care environment complete a 1-year mentorship with a qualified TT practitioner or teacher and participate in an intermediate level workshop. Although no standard requirements or certification to be a TT practitioner exist, the Self-Evaluation Tool of Therapeutic Touch Scale (SETTS), developed by Krieger and Patricia Winstead-Fry, PhD, RN, can be used to assist clients in discriminating between experienced and proficient practitioners and those who are less experienced.²

Another way to determine a practitioner’s level of proficiency is to inquire if the TT practitioner is a qualified to-be instructor. To be recognized by NHP-NA as a qualified TT instructor, the practitioner needs to have practiced TT regularly for 5 years, had 1 year of mentorship, completed two advanced workshops, and had 1 year of teaching mentorship with a qualified TT instructor.

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